The Economic Burden of Illness
Authors: William S. Weintraub
Journal: JAMA Network Open (2023)

What does illness-especially chronic illness-cost?Can we meaningfully estimate total cost?We most commonly consider direct health care costs, especially hospital care and prescription pharmaceuticals.Estimating even these costs can be quite difficult.However, direct health care costs may represent only a fraction of the costs of illness, leading to underestimation of societal economic burden.Published estimates of cost may not include all costs of illness, leaving experienced readers of the literature unsure as to whether all costs are included and which may be left out.One specific cost of illness that has been discussed but rarely estimated is lost labor productivity.Luo et al 1 estimate lost labor productivity elsewhere in JAMA Network Open.The source of data was the 2019 Panels Study of Income Dynamics (PSID), a long-standing survey (begun in 1968) of households in the US designed to assess the dynamics of a nationally representative sample of income and poverty. 2 Since 1997, PSID has provided cross-sectional weights calibrated to US population characteristics, and since 1999, data on chronic diseases.The current study 1 uses the 2019 survey, which includes 9569 families and 26 084 individuals.This study focuses on a reference person in the survey and their spouses.The study is limited to people aged 18 to 64 years, when they are most likely to be in the workforce.Labor income for the year before the survey included wages and salary, bonuses, overtime, tips, commission, professional practice, additional jobs, and miscellaneous.Heart disease and stroke were coded as present if the participant responded "yes" to the question of whether a health care clinician had ever told them they had the condition.There were 12 166 participants, with a prevalence of prior heart disease and stroke of 3.7% and 1.7% respectively.Adjusting for sociodemographic factors and other chronic conditions, people with heart disease would earn $13 463 (95% CI, $6993 to $19 933) and people with stroke would earn $18 716 (95% CI, $10 356 to $27 077) less than people without these conditions.The lost labor for heart disease was approximately 25% of model-predicted mean labor income and approximately 40% for stroke.The authors estimated the total annual income lost in the US in 2018 to be $203.3 billion for heart disease and $63.6 billion for stroke.These numbers are larger than the estimated loss of productivity from early mortality of $119.9 billion for heart disease and $19.4 billion for stroke. 3o et al 1 note several important limitations.The study did not have sufficient detail to estimate the income lost to specific types or severity of heart disease or stroke.Both heart disease and stroke were self-reported and there may have been misclassification.The study is also cross-sectional and could not assess the effect of these diseases over time.The study is also observational, and causation cannot be proven.There may be confounders, such as socioeconomic status, which cannot be readily accounted for, where people with lower income are also more likely to have had prior cardiovascular disease. 4,5A longitudinal study of income over time from before a cardiovascular event to several years thereafter as well as the severity of disease would likely offer more convincing evidence for causality.This study is also only directly applicable in the US.However, the issues that are raised should be considered everywhere.The limitations notwithstanding, Luo et al 1 have conducted an important study.Although causality cannot be proven, it seems likely that heart disease and stroke could lead to substantial loss of income.The economic effects of illness should include both lost labor costs due to lower income, early mortality and effect on employers. 1,3The last is the most difficult to assess and is also potentially in the multiple billions of dollars.The economic cost of illness can be thought of as being composed of direct costs (hospitalization, testing, office visits, pharmaceuticals, medical devices, skilled nursing facilities, and rehabilitation) and indirect costs (lost labor cost, lost costs due to early